Mild Cognitive Impairment Dr. Sridhar Vaitheswaran

Plan What is MCI? What is the prevalence? Will MCI progress to dementia? Can we treat MCI? How to manage MCI? In primary care settings In secondary care settings

What is MCI? Age Associated Cognitive Decline Age Associated Memory Impairment Age Consistent Memory Impairment Age Related Cognitive Decline Benign Senescent Forgetfulness Cognitive Impairment No Dementia Limited Cognitive Disturbance Mild Cognitive Decline Moderate Cognitive Decline Mild Cognitive Disorder Mild Cognitive Impairment Amnestic Non-amnestic Multiple Minimal Dementia Mild Neurocognitive Disorder Self-reported memory complaint Questionable Dementia Stephan et al 2007

Modified from Peterson & Smith 1999 What is MCI? Subjective complaint of memory loss (or single cognitive function domain) Objective evidence of memory impairment (or single cognitive function domain) Generally preserved other cognitive ability Preserved basic day-to-day functioning No other obvious medical, neurologic or psychiatric cause for memory problem Does not meet criteria for dementia Modified from Peterson & Smith 1999

Prevalence of MCI Varies according to definition Reported values: 0.1% - 42% (Stephan et al 2007) MCI (amnestic): 2.5% Self reported memory impairment: 42% In Grampian (85,000 X 0.42) 35,700 older subjects

What is dementia? Impairment in at least 2 or more cognitive domains (memory, language, recognition, praxis, executive function) Impairment in ADL No other obvious medical, neurological or psychiatric cause

Natural history of cognitive decline “Normal” “MCI” Dementia

What is the conversion rate? Mean annual conversion rate to dementia Lonie et al 2010: 11% for aMCI Grundman et al 1996: 15% 25% did not convert to dementia after 10 years (Chertkow et al 2001)

Can we predict conversion? APOE e4 load (Petersen et al 1995), Homocysteine levels (Lehmann et al 1999), LDL/HDL ratio (Corrada et al 2002), Interleukin 6 levels (Yaffe et al 2002) Neuroimaging: Hippocampal volumes, fMRI, PET, SPECT Neuropsychology Others: Smell test, CSF Tau, CSF Amyloid β 42

Points to note Cognitive impairment often noted in persons before they develop dementia MCI group are at increased risk of converting to dementia A significant group of MCI do not convert to dementia & some also revert back to “normal”

Treatment for MCI Non-pharmacological Cognitive interventions Physical exercise

Treatment for MCI-Pharmacological Massoud et al 2007

Treatment recommendations Mental stimulation & Physical exercise No hard evidence for MCI but no harm! Pharmacological No evidence to support any intervention

So…. When a 75-year-old farmer from NE of Scotland complains of subjective memory loss…..

Screen for & manage Treatable physical conditions Vascular & other modifiable risk factors Other mental disorders Presence of dementia Multiple cognitive impairment Impaired ADL Fitness/willingness for physical exercise Feasibility & willingness to try mental activity

Then… If in doubt refer….

What can secondary service offer? Clinical assessment to rule out dementia/other disorders Imaging Neuropsychology Follow-up????

References Corrada M, Kawas C. Plasma total cholesterol, LDL, HDL levels and the risk of Alzheimer disease: the Baltimore Longitudinal Study of Aging. Neurology 2002;58:A106 Graham JE, Rockwood K, Beattie BL, Eastwood R, Gauthier S, Tuokko H, et al. Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet 1997; 349: 1793 – 1796 Grundman M, Petersen RC, Morris JC. ADSC Cooperative Study: rate of dementia of the Alzheimer type (DAT) in subjects with mild cognitive impairment. Neurology 1996;46:A403 Lehmann M, Gottfries CG, Regland B. Identification of cognitive impairment in the elderly: homocysteine is an early marker. Dement Geriatr Cogn Disord 1999;10:12–20 Lonie JA, Parra-Rodriguez MA, Tierney KM, et al. Predicting outcome in mild cognitive impairment: 4-year follow up study. British Journal of Psychiatry 2010; 197: 135 – 140 Massoud F, Belleville S, Bergman H, Kirk J et al. Mild cognitive impairment and cognitive impairment, no dementia: Part B, therapy. Alzheimer’s & Dementia 2007: 3: 283 - 291 Petersen RC, Smith GE, Ivnik RJ, Tangalos EG, Schaid DJ, Thibodeau SN, et al. Apolipoprotein E status as a predictor of the development of Alzheimer’s disease in memory-impaired individuals [published erratum appears in JAMA 1995;274:538]. JAMA 1995;273:1274–1278 Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999; 56: 303 – 308 Stephan BCM, Mathews FE, McKeith IG, Bond J, Brayne C. Early cognitive change in the general population: how do different definitions work? J Am Geriatr Soc 2007; 55: 1534 – 1540